Healthcare Provider Details

I. General information

NPI: 1174283246
Provider Name (Legal Business Name): WILD APPLE EYE II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 BROADWAY ST
COLCHESTER CT
06415-1022
US

IV. Provider business mailing address

163 BROADWAY ST
COLCHESTER CT
06415-1022
US

V. Phone/Fax

Practice location:
  • Phone: 860-537-2020
  • Fax:
Mailing address:
  • Phone: 860-537-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS PARADIS
Title or Position: OWNER
Credential: OD
Phone: 860-391-3366